Lyndon Johnson famously observed during his presidency that the best way to tame one's antagonists, or at least to mute their mischief, is to keep them close. In LBJ's characteristically inelegant words, it's always better to have the mischief-makers "inside the tent pissing out," rather than "outside the tent pissing in."

The LBJ aphorism came to mind yesterday as President Obama stood at the White House with the major players of the health care industry - all of whom, under different political circumstances, might ideally be tempted to urinate on health care reform from a great height... just as the major players did back in 1994, when they hooked up with the ascendant congressional Republicans to bury the Clinton reform plan.

But it's not 1994 anymore; the congressional Republicans have been driven to the margins of governance, and the polls show strong public support for government-driven reform. In February, for instance, a CNN-ORC poll asked, "In general, would you favor or oppose a program that would increase the federal government's influence over the country's health care system in an attempt to lower costs and provide coverage to more Americans?" The response: 72 percent favored, 27 percent opposed. Meanwhile, in early April, the CBS-New York Times poll reported that 57 percent of Americans are "willing to pay higher taxes so that Americans have health insurance they can't lose, no matter what." Granted, the devil is always in the details, but the general mood is unmistakable; as a subsequent the CBS-NYT poll reported, 87 percent of Americans support either "fundamental changes" in the health care system, or prefer to "completely rebuild" the system.

All of which is why the medical, pharmaceutical, and private insurance players have decided (with goading from the Obama administration) that it would be far wiser to position themselves inside the tent. Which is why they showed up at the White House yesterday with a good-faith pledge to lower their own costs by $2 trillion over the next 10 years ($2500 per typical family), clearly hoping (to borrow a Dylan phrase) that this gesture will give them shelter from the storm.

And at the White House event, Obama took full rhetorical advantage. He was in bipartisan mode: "This is a historic day, a watershed event in the long and elusive quest for health care reform...(which will) require all of us coming together, as we are today, around a common purpose - workers, executives, hospitals, nurses, doctors, drug companies, insurance companies, members of Congress. It's the kind of broad coalition, everybody with a seat at the table that I talked about during the campaign." (Obama is following up today with a business roundtable on ways to cut employer health-care costs.)

Obviously, the health care industry is entering the Obama tent with its own best interests in mind. It's a bit vague on how it plans to achieve those voluntary, unenforceable savings (which, after all, could wind up shaving their own profits), and clearly the industry figures that it can best achieve one of its most self-interested goals by working from the inside, as opposed to lobbying from the outside.

That goal, of course, is to topple one of the pillars of health care reform: the creation of a "public option," whereby Americans would have the choice of buying into a public health insurance plan, as an alternative to the plans offered by private insurers. More specifically, those Americans who can't get coverage at work or who can't qualify for Medicaid would be able, under the public option, to buy some health coverage.

All the details of a public option plan would have to be hashed out in the congressional sphere during the summer, but here's the bottom line: Such a plan would create competition for the private health insurance industry. And the industry doesn't want competition.

So the industry will fight that reform as it always has. But it's hard to see how the lobbyists can obstruct as effectively from the inside, with Obama hugging them close. Yes, they're pledging voluntary savings merely to slow the reform momentum. But they're going to look particularly craven a few months from now if they suddenly leave the tent. And it's questionable whether, as outsiders, they would get any traction from crafting a new version of the "Harry and Louise" TV ads that worked so well 15 years ago, in a different political era.

Granted, there was much talk back in the early '90s that the political moment for national health care reform had arrived; in 1991, the editor of the American Medical Association's Journal wrote that such reform had the air of "inevitability." But the health care industry's top players never stood shoulder to shoulder with Bill Clinton at a White House event; they never gave Clinton a golden opportunity to drive a wedge between themselves and their traditional Republican friends. They have done so with Obama. The political optics today contrast sharply with those of 15 years ago.

This hardly means, of course, that substantive reform ultimately will be enacted to everyone's satisfaction; it does mean, however, that the political prospects are brighter than before. And health care industry aside, if you really want an accurate barometer, just check out Arlen Specter.

On TV nine days ago, the new Democratic senator from Pennsylvania said he opposed a public health insurance option that would compete with private insurers. But now, in a letter to a progressive health care group, he says he is open to a public health insurance option, that he looks forward to "discussing and considering" such an option.

Forgive me for rewriting Dylan:

You only need an Arlen to know which way the wind blows.

Published: May 12, 2009 — 10:20 AM EDT

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